Because geriatric patients frequently have multiple healthproblems. Research has continued to highlight the complexity. AmericanGeriatrics Society (AGS) recommends starting treatment with acetaminophen;NSAIDs are traditionally the next step.However, there is heightened risk of GI toxicity, effects on renal function,and cardiovascular problems ie, myocardial infarctions and strokes.It therefore concludes that for manygeriatric patients, other drugs—including opioids—may be a safer choice.

There ispotential promise of topicalNSAIDs but even these medications are far from risk-free. About 17.5%reportedsystemic adverse effects. Up to another 39% of patients had problems atthe application site of the topical drug, and there were 5 cases ofwarfarin potentiation.

Yet to be answered is the very important question of whether the topical NSAIDsare as effective as the oral ones for chronic pain.

With regard to opioids, geriatric patients are at risk for abuse anddependence. Delirium is of special concern in the geriatric population..Benzodiazepines and opioids combo, appear to be most likely to increase therisk. The AGS guideline notes that benzodiazepines have little role in themanagement of chronic pain. Oxycodone has least risk of contributing todelirium and meperidine (Demerol), the most.

The majority of the studies of oxycodone , immediate-releaseformulation was used rather than the extended-release formulation, because theextended-release form may accumulate andit might be more strongly associated with delirium.

One especially interesting finding was that in severe acute pain like in hipfractures, lower doses of opioids were associated with an increased risk ofdelirium.

The AGS guideline mention that Neuropathic pain (eg, diabetic neuropathic painand postherpetic neuralgia) can occur at any age but is more likely to afflictolder persons. Although opioids can provide some benefit, the non-opioidsappear to be more effective for these conditions.

These include:

• Anticonvulsants such as Pregabalin (Lyrica) and (Neurontin)

• Antidepressants, including the tricyclics and other serotonin-norepinephrinereuptake inhibitors, such as Duloxetine ,(Cymbalta) and venlafaxine (Effexor)